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Surgical Management of Gastric Cancer: a Systematic Review

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Surgical Management of Gastric Cancer: a Systematic Review Journal of Clinical Medicine Review Surgical Management of Gastric Cancer: A Systematic Review Lucian Mocan 1,2 1 Department of Surgery, Iuliu Hatieganu University of Medicine and Pharmacy, RO-400012 Cluj-Napoca, Romania; [email protected] or [email protected]; Tel.: +40-745-362-345 2 Regional Institute of Gastroenterology and Hepatology, 19-21 Croitorilor Street, RO-400162 Cluj-Napoca, Romania Abstract: Gastric cancer is the fifth most common cancer worldwide, and it is responsible for 7.7% of all cancer deaths. Despite advances in the field of oncology, where radiotherapy, neo and adjuvant chemotherapy may improve the outcome, the only treatment with curative intent is represented by surgery as part of a multimodal therapy. Two concepts may be adopted in appropriate cases, neoadjuvant treatment before gastrectomy (G) or primary surgical resection followed by chemotherapy. Such an approach, combined with early detection and better screening, has led to a decrease in the overall incidence of gastric cancer. Unfortunately, malignant tumors of the stomach are often diagnosed in locally advanced or metastatic stages when the median overall survival remains poor. Surgical care in these cases must be provided by a multidisciplinary team in a high-volume center. Important surgical aspects such as optimum resection margins, surgical technique, and number of harvested lymph nodes are important factors for patient outcomes. The standardization of surgical treatment of gastric cancer in accordance with the patient’s profile is of decisive importance for a better outcome. This review aims to summarize the current standards in the surgical treatment of gastric cancer. Keywords: gastric cancer; surgery; lymphadenectomy; survival Citation: Mocan, L. Surgical Management of Gastric Cancer: A Systematic Review. J. Clin. Med. 2021, 1. Introduction 10, 2557. https://doi.org/10.3390/ Gastric cancer is the fifth most common cancer worldwide, and it is responsible jcm10122557 for 7.7% of all cancer deaths. Although surgical treatment for gastric cancer has been considerably improved during recent decades, the mortality rate from gastric cancer is Academic Editor: Hiroyuki Yoshida still high [1]. Statistical data show that the 5-year survival rate for patients treated with curative intent (gastric resection and lymphadenectomy) is 70% for stage I resected gastric Received: 18 May 2021 cancer and less than 30% for stage IIB disease and beyond [2]. Most gastric tumors are Accepted: 7 June 2021 Published: 9 June 2021 adenocarcinomas [3]. Despite advances in the field of oncology, where radiotherapy, neo and adjuvant chemotherapy may improve the outcome, the only treatment with curative Publisher’s Note: MDPI stays neutral intent is represented by surgery as part of a multimodal therapy [4]. Two concepts may with regard to jurisdictional claims in be adopted in appropriate cases, neoadjuvant treatment before gastrectomy or primary published maps and institutional affil- surgical resection followed by chemotherapy [5]. iations. Genetic alterations responsible for the development and progression of gastric cancer such as cell adhesion, signal transduction, DNA methylation, and glycosylation changes may lead to early detection of gastric cancers using these biomarkers [6]. For patients with hereditary diffuse gastric cancer (HDGC), who carry a lifetime gastric cancer risk of approximately 70% in men and 56% in women, a prophylactic total Copyright: © 2021 by the author. Licensee MDPI, Basel, Switzerland. gastrectomy at the age of 20 years is the procedure of choice [7]. Recently, there have This article is an open access article been numerous sources of evidence establishing the importance of combining systemic distributed under the terms and chemotherapy with surgery in advanced gastric cancer. Given the latest results, there conditions of the Creative Commons has been a shift in the paradigm of gastric cancer treatment with the increasing use of Attribution (CC BY) license (https:// preoperative and postoperative chemotherapy [8]. creativecommons.org/licenses/by/ Unfortunately, malignant tumors of the stomach are often diagnosed in locally ad- 4.0/). vanced or metastatic stages when the median overall survival remains poor [9]. Surgical J. Clin. Med. 2021, 10, 2557. https://doi.org/10.3390/jcm10122557 https://www.mdpi.com/journal/jcm J. Clin. Med. 2021, 10, x FOR PEER REVIEW 2 of 11 J. Clin. Med. 2021, 10, 2557 2 of 11 Unfortunately, malignant tumors of the stomach are often diagnosed in locally ad- vanced or metastatic stages when the median overall survival remains poor [9]. Surgical carecare inin thesethese casescases mustmust be provided by a a multidisciplinary multidisciplinary team team in in a ahigh-volume high-volume center cen- ter[10]. [10 Important]. Important surgical surgical aspects aspects such such as as opti optimummum resection resection margins, margins, surgical technique,technique, numbernumber ofof harvested harvested lymph lymph nodes nodes are are important important factors factors for patientfor patient outcomes. outcomes. The stan- The dardizationstandardization of surgical of surgical treatment treatment of gastric of gast cancerric cancer in accordance in accordance with the with patient’s the patient’s profile isprofile of decisive is of importancedecisive importance for a better for outcome a better (Figure outcome1). This(Figure review 1). This aims review to summarize aims to thesummarize current standards the current in standards the surgical in treatmentthe surgical of treatment gastric cancer. of gastric cancer. FigureFigure 1. 1.Treatment Treatment strategies strategies of of gastric gastric cancer cancer according according to TNMto TNM stage. stage. Stage Stage 0: TisN0M0; 0: TisN0M0; stage stage IA: IA: T1N0M0; stage IB: T2N0M0; stage II: T1N2M0/T2N1M0/T3N0M0; stage IIIA: T1N0M0; stage IB: T2N0M0; stage II: T1N2M0/T2N1M0/T3N0M0; stage IIIA: T3N1M0/T4N0M0; T3N1M0/T4N0M0; stage IIIB: T3N2M0; stage IV: T3N1-3M0/T1-3N3M0/T1-4N0-3M1 (Tis—the stage IIIB: T3N2M0; stage IV: T3N1-3M0/T1-3N3M0/T1-4N0-3M1 (Tis—the mucosa; T1— mucosa; T1—submucosa;T2—muscle layer; T3—subserosa; T4—serosa/adjacent struc- submucosa;T2—muscletures/N0—(0+)LN; N1—(1–2+)LN; layer; T3—subserosa; N2—(3–6+)LN; T4—serosa/adjacent N3—(>7+)LN/M0—no structures/N0—(0+)LN; metastasis; M1—distant N1—(1– 2+)LN;metastasis N2—(3–6+)LN; or carcinomatosis); N3—(>7+)LN/M0—no LN—lymph node metastasis;s; ST—subtotal; M1—distant T—total; metastasis ChT—chemotherapy; or carcinomato- sis);ChRxT—chemo-radiotherapy; LN—lymph nodes; ST—subtotal; preop—pr T—total;eoperative; ChT—chemotherapy; postop—postoperative. ChRxT—chemo-radiotherapy; preop—preoperative; postop—postoperative. 2. Results and Discussion 2. Results and Discussion 2.1.2.1. ExtentExtent ofof GastricGastric Resection:Resection: TotalTotal Gastrectomy Gastrectomy (TG), (TG), Subtotal Subtotal Gastrectomy Gastrectomy (SG), (SG), and and ProximalProximal Gastrectomy Gastrectomy (PG) (PG) TheThe extent extent of of surgical surgical resection resection required required to achieveto achieve surgical surgical margins margins free free of malignant of malig- cells,nant R0,cells, depends R0, depends on the on size, the location,size, location, and histological and histological type oftype the of tumor. the tumor. The optimal The op- lengthtimal length for the for proximal the proximal margin margin is often is suggested often suggested to be at to least be at 3 toleast 5 cm 3 to depending 5 cm depending on the tumoron the histology tumor histology [11]. However, [11]. However, recent studies recent suggeststudies thatsuggest resection that resection margins ofmargins 1 cm may of 1 becm comparable may be comparable in terms ofin survivalterms of andsurvival oncological and oncological outcome [outcome12]. [12]. SinceSince thethe standard standard approach approach for for gastric gastric cancer cancer with with any any localization localization is total is total gastrec- gas- tomytrectomy (TG), (TG), several several studies studies have shownhave shown that the that outcomes the outcomes of patients of patients with proximal with proximal tumors whotumors underwent who underwent TG or proximal TG or proximal gastrectomy gastre (PG)ctomy were (PG) similar were insimilar terms in of terms the overall of the survivaloverall survival interval interval and disease-free and disease-free interval interv [13].al Following [13]. Following these studies, these studies, it is accepted it is ac- todaycepted that today both that procedures both procedures could be accomplishedcould be accomplished safely. Some safely. authors Some suggest authors that suggest distal gastrectomythat distal gastrectomy can be safely can performed be safely for perf patientsormed withfor patients distal lesions with anddistal TG/PG lesions may and be performed for proximal lesions [14]. The benefit of PG for the surgical treatment of proximal cancers was assessed by Harrison et al. [15], and the researchers showed that J. Clin. Med. 2021, 10, 2557 3 of 11 patients with proximal tumors who underwent PG resection had similar overall survival and disease-free intervals compared with patients who underwent TG resection. The only concern related to PG was represented by the increased number of patients who experi- enced late complications, such as esophageal reflux [16]. Several trials [17–21] addressed the issues of postoperative mortality, morbidity, and long-term outcome of TG versus subtotal gastrectomy (SG) for distal tumors. The wound
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